Chapter 2B: 837 Institutional Claim

Transcription

1 Chapter 2 This Companion Document explains how to submit the 837 Institutional Health Care Claim to Anthem Blue Cross and Blue Shield (Anthem). It applies to all trading partners including those eligible for an NPI and those who are exempt from the NPI (such as taxi services, home modifications, vehicle modifications, insect control, and respite services). Data Elements Critical to Processing Type Loop(s) Data Element Notes NPI Provider 2010AA (Billing Provider Name) When using NPI, NM108 = XX and NM109 = NPI. Tax ID Number 2010AA (Billing Provider Name) If REF01 (Reference Identification Qualifier) = EI, then REF02 (Billing Provider Additional Identifier) = Tax ID Number. Provider Name 2010AA (Billing Provider Name) In NM103 (Billing Provider Last or Organizational Name) enter the provider name noted on the W-9 (Request for Taxpayer Identification Number and Certification). Physical Address 2010AA (Billing Provider Name) Do not enter a post office box address in N301 (Billing Provider Address Line). Enter the physical address of the institution. Bill Type 2300 (Claim Information) For 837 Institutional claims, we use CLM05 (Health Care Service Location Information) to identify the place of service. Service Facility Name Taxonomy Code 2310E (Service Facility Name) 2000A (Billing/Pay-To Provider Hierarchical Level) Complete the NM1 (Service Facility Name) segment if the services were rendered at a different location than entered in 2010AA N301. PRV03 (Provider Taxonomy Code): When using NPI, enter the taxonomy code that applies to the services on the claim you are filing. (Note to Clearinghouses: Do not default.) Section 2.2 of this document includes charts to explain the 837 data elements that (1) require specific information for Anthem and (2) are beyond the instructions in the ASC X12N 837 Implementation Guide (837 IG) for Institutional Claims. If a data element does not need additional information for Anthem, then it is not documented in this Companion Document. Therefore, please use this document as an addition and companion to the 837 IG. The 837 is divided into two levels as follows: The Header level contains transaction control information. The Detail level contains the detail information for the transaction s business function. Note: Before the 837 claim goes to processing, it must pass initial compliance and formatting checks. For complete information, see Part I, Chapter 7, Acknowledgments and Reports, and Part II, Chapter 8, Virginia Business Edits. This Companion Document is divided into the following sections: Section Title Page 2.1 : Basic Instructions Charts 2-13 (September 2010) Part II: 2-1 Anthem, Virginia

2 2.1 : Basic Instructions This section provides information that trading partners need to understand before starting the 837 Institutional transaction. The remaining sections of this Companion Document include charts that provide information about 837 segments and data elements that require specific instructions to efficiently process through Anthem systems. Use the information in this Companion Document in conjunction with the 837 Implementation Guide for Institutional Health Care Claims, including the 10/2002 Addenda ANSI ASC X12N Compliant Codes When entering codes in an 837 Institutional transaction, carefully follow the 837 including the 10/2002 Addenda. Use all of the compliant codes as stated in the IG and the following ANSI ASC X12N compliant codes from current versions of the following sources: Physician s Current Procedure Terminology (CPT) Health Care Financing Administration Common Procedural Coding System (HCPCS) International Classification of Diseases Clinical Mod (ICD-9-CM) Procedures and Diagnosis Provider Taxonomy Codes National Drug Code We accept all ANSI ASC X12N compliant code sets ANSI ASC X12N Compliance Checking and Business Edits Use Upper Case Alpha Characters in the 837 Transaction EDI interchanges submitted to Anthem and continuing through processing pass through three edit levels. Level 1 Edits: Upon receipt of an EDI interchange, the Enterprise EDI Gateway performs Level 1 edits to check X12 syntax compliance. After Level 1 editing, the Enterprise EDI Gateway sends a 997 Functional Acknowledgment to confirm receipt and report any Level 1 errors. Level 2 Edits: Level 2 edits check for compliance with X12N Implementation Guides. After Level 2 editing, the Enterprise EDI Gateway sends a Level 2 Status Report which identifies how many 837 transactions (claims) passed and/or failed Level 2 edits and reports any errors. If some claims within a functional group (GS/GE) pass Level 2 edits and others do not, the Enterprise EDI Gateway removes the non-compliant claims, adjusts the envelope segment count and sends the functional group with the remaining valid claims to processing. The Level 2 Status Report clearly reports claims that passed and claims that failed. Level 3 Business Edits: In addition to checking compliance, we apply VA Business edits to 837 transactions. For example, for Loop 2010BA, NM108 (Identification Code Qualifier) must equal MI (Member Identification Number). If values do not comply with the edits, we will deem the claim in error and return the Level 3 Adjudicated Claims Response report. If the claim passes VA Business editing with no errors, we will send notification on the Level 3 Adjudicated Claims Response. When entering alpha characters into the 837, use only UPPER- CASE. As specified in the 837 IG, the basic character set includes uppercase letters, digits, space, and other special characters. For further information, see the 837 IG. (September 2010) Part II: 2-2 Anthem, Virginia

3 2.1.4 Coordination of Benefits For coordination of benefits (COB), we use the process identified in the IG as, Model 1 Provider-to-Payer-to-Provider. The Model 1 COB process includes the following steps: 1. The provider sends the 837 to the primary payer. 2. The primary payer adjudicates the claim and sends an 835 Payment Advice to the provider. The 835 includes the claim adjustment reason code for the claim. 3. Upon receipt of the 835, the provider sends a second 837 to the secondary payer. 4. The secondary payer adjudicates the claim and sends an 835 Payment Advice to the provider. For an 837 Institutional claim, the following chart identifies the required data elements that pertain to coordination of benefits when Medicare or another carrier is primary and Anthem is secondary or tertiary. In lieu of using the 837 to send COB information as explained in the chart below, providers have the option to either file a paper claim, or use the PWK segment (Attachments) to denote that COB documentation will be sent separately. Based on the information you provide, the secondary claim may be adjudicated without the paper copy of the explanation of benefits from the other insurance carrier. If you do not send the Medicare or other carrier s EOB, then all data elements in the following chart are required. Institutional 837 COB Anthem Secondary/Tertiary This chart includes only COB-related data elements necessary for Anthem when Anthem is secondary or tertiary. For complete 837 information, use the charts in Section 2.2 of this Companion Document along with the IG. Segment Data Element Information and Instructions Loop 2000B Subscriber Level SBR Subscriber Information 837 Institutional IG Page 101 Medicare & SBR01 Payer Responsibility Sequence Number Code HI0X-2 Value Code This data element indicates whether this claim is Primary (P), Secondary (S) or Tertiary (T). If the value equals S or T, then either the data elements documented in this chart are required, or Loop 2300 (Claim Supplemental Information), PWK01 (Attachment Report Type Code) must equal EB (Explanation of Benefits). Loop 2300 Claim Information HI There are up to 12 occurrences of this segment. The X in the reference designator (HI0X) can Value Information represent any of the numerals 1 through 12, depending on the number of occurrences. HI0X-1 Enter BE (Value) 837 Institutional Code List Qualifier Code IG Page 280 Blood Deductible Medicare Only HI0X-5 Value Code Associated Amount Enter 06 (Medicare Blood Deductible) Enter the Blood Deductible amount from the Medicare EOMB. For an explanation of how to enter monetary amounts, see Section 2.1.5, R (Decimal) Data (September 2010) Part II: 2-3 Anthem, Virginia

4 (Continued) Institutional 837 COB Anthem Secondary/Tertiary This chart includes only COB-related data elements necessary for Anthem when Anthem is secondary or tertiary. For complete 837 information, use the charts in Section 2.2 of this Companion Document in conjunction with the IG. Segment Data Element Information and Instructions Loop 2320 Other Subscriber Information SBR SBR01 Other Subscriber Information 837 Page 359 CAS Claims Level Adjustments 837 Page 365 Medicare & Payer Responsibility Sequence Number Code Enter the appropriate value (P for Primary, S for Secondary, or T for Tertiary) to identify the other insurance carrier(s) level of responsibility for payment of this claim. As indicated in the chart below, you can report deductible amounts, coinsurance amounts, and non-covered services in the CAS Segment HI Value Information 2320 CAS Claims Level Adjustments Deductible Coinsurance Non-Covered Services 2320 AMT COB Total Non- Covered Amount Medicare & CAS01 Claim Adjustment Group Code CAS02 Adjustment Reason Code CAS03 Adjustment Amount Enter the appropriate Adjustment Group Code found on the 835 Payment Advice, EOB, EOMB, or remittance. Enter the appropriate Adjustment Reason Code found on the 835 Payment Advice, EOB, EOMB, or remittance. Enter the Adjustment Amount found on the EOB, 835 Payment Advice, or EOMB when deductible, coinsurance, copayment and/or non-covered services are reported. For an explanation of how to enter monetary (September 2010) Part II: 2-4 Anthem, Virginia

5 (Continued) Institutional 837 COB Anthem Secondary/Tertiary This chart includes only COB-related data elements necessary for Anthem when Anthem is secondary or tertiary. For complete 837 information, use the charts in Section 2.2 of this Companion Document in conjunction with the IG. Segment Data Element Information and Instructions (Continued) Loop 2320 Other Subscriber Information AMT Payer Prior Payment 837 Page 371 AMT Coordination of Benefits Total Allowed Amount 837 Page 372 AMT Coordination of Benefits Total Submitted Charges 837 Page 373 AMT Coordination of Benefits Total Medicare Paid Amount 837 Page 376 AMT Coordination of Benefits Total Non- Covered Amount 837 Page 386 Only AMT01 Amount Qualifier Code AMT02 Other Payer Patient Paid Amount Enter C4 (Prior Payment) For an explanation of how to enter monetary You can report non-covered amounts in either this AMT Segment as explained below or in the CAS (Claims Level Adjustment) Segment. Medicare & Medicare Only Medicare Only Medicare & AMT01 Amount Qualifier Code AMT02 Allowed Amount AMT01 Amount Qualifier Code AMT02 Coordination of Benefits Total Submitted Charge Amount AMT01 Amount Qualifier Code AMT02 Total Medicare Paid Amount Enter B6 (Allowed-Actual) For an explanation of how to enter monetary Enter T3 (Total Submitted Charges) For an explanation of how to enter monetary Enter N1 (Net Worth) For an explanation of how to enter monetary You can report non-covered services in this segment or in 2320 CAS (Claim Level Adjustments). AMT01 Enter A8 (Non-Covered Charges-Actual) Amount Qualifier Code AMT02 Non-Covered Charge Amount For an explanation of how to enter monetary Loop 2330A Other Subscriber Name NM1 Other Subscriber Name 837 Page 400 Medicare & NM103 Other Insured Last Name NM104 Other Insured First Name NM109 Other Insured Identifier Loop 2330B Other Payer Name NM1 NM103 Other Payer Name 837 Page 410 Medicare & Other Payer Last or Organization Name Enter the insured s last name. Enter the insured s first name. Enter the Other Insurance Member Identification Number. Enter the name of the other insurance carrier. (September 2010) Part II: 2-5 Anthem, Virginia

6 2.1.5 R (Decimal) Data Elements R data elements are those that may contain a decimal point. R data elements involve amounts such as monetary amounts, units, visits, weight, and frequency. We recommend that you use the decimal point for monetary amounts, but not for other types of R data elements. Monetary Amounts For all monetary amounts, include trailing zeros for precision. Examples: For $100.00, enter For $12.34, enter For no charge instances such as Room and Board for revenue codes 0183 and 0189, enter All Other R Data Elements For units, visits, weight, frequency, and other R data elements that are not monetary amounts, we recommend that you enter only whole numbers and not include a decimal or numbers after the decimal. You should round any amount that is less than one or any fraction of an amount to the nearest whole number. Except for monetary amounts, if we receive an R data element that includes a decimal and numbers after the decimal, then we adjudicate the claim based on the whole number. Numbers after the decimal will not be considered Notes NTE Segments The Institutional 837 includes two NTE (Notes) segments, both at the claim level (Loop 2300) as follows: NTE Claim Note NTE Billing Note Each of the NTE segments allows up to 80 bytes. The Claim Note can be repeated up to 10 times (800 total bytes) and the Billing Note allows no repetition (80 bytes). Therefore, the Claim Note plus the Billing Note allows a total of 880 bytes. When appropriate, if supplemental information can be conveyed in 880 bytes or less, use the NTE segments rather than sending attachments. It is preferable to keep notes within the allotted Claim Note 800 bytes. If a Claim Note requires more than 800 bytes, you may begin the note in the Claim Note NTE segment and continue it in the Billing Note NTE segment. The continuation is called overflow. When notes apply to a specific service rendered, enter the corresponding Service Line Number from Loop 2400 LX01 at the beginning of the text. Unlisted or Non-Specific Supplies and Equipment When appropriate, include the manufacturer s description of the supply or equipment in an NTE segment. Include Only Pertinent Information in NTE Segments In NTE segments, include only pertinent information. Information such as Anthem Blue Cross and Blue Shield, the name of the other insurance carrier or not a duplicate, may delay processing. For more information on services that require either notes or attachments, see Section 2.1.7, Attachments PWK Segment (below) and 2.1.8, Note and PWK Attachment Chart for Institutional 837. (September 2010) Part II: 2-6 Anthem, Virginia

7 2.1.7 Attachments PWK Segments The Institutional 837 includes the following two PWK (Paperwork) segments: Loop 2300 PWK (Claim Supplemental Information) This claim level PWK segment is intended to identify supplemental documentation that pertains to the entire claim. Loop 2400 PWK (Line Supplemental Information) This line level PWK segment is intended to identify supplemental documentation that pertains to a particular service rendered. When documentation is necessary to support an Institutional 837, identify the documentation using one of the two PWK (Paperwork) Segments. Separately fax or mail the actual supporting documentation. Note: You may continue to file attachment claims according to current billing guidelines by sending a paper claim with the attachment. Obtain Appropriate Authorizations as Necessary to Avoid Unnecessary Paperwork To avoid unnecessary paperwork, be sure to obtain any required authorizations, referrals or inpatient admissions and enter the authorization number into Loop 2300 (Claim Information), REF02 (Referral Number). More information about contracts and services that require authorizations is available at Once on the site, select Providers, then choose Virginia. You will find a link to the Point of Care site on the Virginia home page. Use Notes (NTE) Segments When Appropriate In lieu of attachments, you may use the Notes (NTE) Segments if and when appropriate to help describe the service. For example, you may be able to use the NTE segments for unlisted procedure codes or to provide accident information. Attachment Procedure To identify and send attachments for institutional claims, use the following procedure. 1. Create and transmit the Institutional 837 according to instructions in the IG and this Companion Document. If the supporting documentation applies to the entire claim, complete Loop 2300 PWK segment. If the supporting documentation applies to a particular service rendered, complete Loop 2400 PWK segment. For either PWK segment, use following data elements to identify that a paper attachment is forthcoming. PWK01, Attachment Report Type Code Use the values indicated in the IG to identify the type of attachment. PWK02, Attachment Transmission Code Use the following values indicated in the IG to identify how you will send the attachment. The codes Anthem uses include: AA (Available on Request at Provider Site) BM (By Mail) FX (By Fax) - EL (Electronic attachment) ( is not available at this time.) (September 2010) Part II: 2-7 Anthem, Virginia

8 PWK05, AC (code for attachment control number) PWK06, Attachment Control Number Use if PWK02 equals BM, FX, or EL If using PWK06 qualifer EL and provider is using Medical Electronic Attachment Vendor (MEA) for claims attachment, please enter MEA and all alpha/numeric characters assigned as your tracking number. ( Ex: MEA12345B ) 2. If using PWK06 qualifier BM or FX please Prepare a 151 Claim Information/Adjustment Request (151) for each patient and claim requiring supporting documentation. Complete the following fields on the 151: Attachment Control Number* Policyholder ID# Patient Name NPI (For NPI exempt providers Anthem Provider Number) Date of Service *The Attachment Control Number must be a unique identifier for each attachment claim and it must match the number entered into PWK06 (Attachment Control Number). Construct the Attachment Control Number as indicated below: Attachment Control Number Member Identification # (Including any prefix) as shown on the ID card Distinctive Provider-Assigned Sequence Number or may remain unused. Recommendation: Use the Patient Control Number or other pertinent office identifier YTA MMDDCCYYXXXXXXXXXX NPI Date of Service If the Attachment Control Number is not used, the claim and the supporting documentation cannot be matched, possibly resulting in a claim denial. Multiple Attachments: When more than one supporting document is needed for a claim (such as Emergency Room and Operative Reports), use the same 151 to send multiple attachments. In this case, indicate on the 151 that there are multiple documents attached. If one claim requires multiple attachments, use the same Attachment Control Number as entered in PWK06 (Attachment Control Number). Assign one attachment control number. Illegible information will delay processing. 3. Send the attachment using the sending method identified in PWK02. Please abide by the following guidelines when sending support documentation: Send attachments the day before or the day of filing the claim. Do not send a copy of claim with the attachment. Do not send unnecessary attachments. For example, do not send a copy of the member identification card. If you send supporting documentation by mail or fax, include the attachment control number in the upper right hand corner of the (September 2010) Part II: 2-8 Anthem, Virginia

9 2.1.8 NTE and PWK Attachment Chart for Institutional 837 supporting documentation. Attach the documentation to the 151 Claim Information Adjustment Request Form with all fields completed, including the attachment control number. ( is not available at this time.) Send the supporting documentation to the following address or fax number: Mailing Address: P.O. Box Richmond, Va Fax Number: (804) Electronic Attachment Claims Rejected Due to ANSI ASC X12N Compliance or Virginia Business Edits When a claim is rejected due to ANSI ASC X12N Compliance or Virginia Business Edits, correct the claim and use the same Attachment Control Number (PWK06) as used for the original claim transmission. Because the supporting documentation was already mailed or faxed, we will hold it to match with the claim once it is received. If a new Attachment Control Number is assigned for the retransmission of the claim, you need to resubmit the supporting documentation and reference the new Attachment Control Number. What Happens When Necessary Attachments or Notes Are Not Provided? When a claim is submitted that requires either notes or attachments and the claim has neither, we deny the claim and request the information. We reopen the claim when the attachment arrives. The following chart specifies procedures or services that require either supporting documentation or notes. Supporting documentation is faxed or mailed separately. Therefore, when supplemental information can be conveyed in 880 bytes or less it is preferable to use the note segments (2300 NTE) in lieu of sending supporting documentation. If you submit a claim requiring notes or attachments and we do not receive the supporting documentation, we deny the claim and request the documentation. When the attachment arrives, we reopen the claim. Please note that although the following chart below documents the most common situations that call for either notes or supporting documentation, we may still request additional information. Situations that do not fall into the categories in the chart below may still warrant additional information. Also, we may need additional information after reviewing the information initially submitted. All requests for additional supporting documentation will be in writing and will specifically ask for the information necessary to review the claim. NTE and PWK Attachment Chart for Institutional 837 Revenue Codes (Inpatient or Outpatient as Applicable) Lab or Pathology Revenue Codes Ending in 9 (Other) Radiology Revenue Codes Ending in 9 (Other) Other Revenue Codes Ending in 9 (Other) HCPCS Procedure Codes (Outpatient) Unlisted and Non-Specific Supporting Notes and/or Attachments A complete description of the service or procedure Attach Pathology and/or Lab Report as applicable. A complete description of the service or procedure Attach X-ray Report as applicable. Complete description of the accommodation, service, supply or special charge. Supporting Notes and/or Attachments A complete description of the service or procedure (September 2010) Part II: 2-9 Anthem, Virginia

10 Surgery and Maternity Procedure(s) Unlisted and Non-Specific Radiology Procedure(s) Unlisted and Non-Specific Pathology and Laboratory Procedure(s) Other Unlisted or Non-Specific Services or Procedures that Are Not Specifically Listed as Requiring Attachments Attach Operative Report as applicable. A complete description of the service or procedure Attach X-ray Report as applicable. A complete description of the service or procedure Attach Pathology and/or Lab Report as applicable. Complete description of the service or procedure Filing Electronic Claims with Adjustment Information The ANSI X claim format allows you to electronically submit claims for (1) charges not included on a prior claim and/or (2) other adjustment information. This electronic filing method does not require using an Anthem Claim Adjustment Request (151). Indicating a Claim Adjustment Claim Frequency Codes The 837 Implementation Guides refer to the National Uniform Billing Data Element Specifications Type of Bill Position 3 (UB92, Type of Bill, third position) for explanation and usage. In the 837 formats, the codes are called claim frequency codes. Specific codes indicate that the claim is an adjustment of a previously submitted claim. The codes are as follows: Claim Frequency Code Description Code/Name 5 Late Charge(s) Use to submit additional charges for the same dates of service (statement covers period) as a previous claim. We will add the late charges to the previously processed claim. 7 Replacement of Prior Claim 8 Void/Cancel of Prior Claim Use to replace an entire claim (all but identity information). We will consider the original claim null and void and replace it with the new claim. Use to entirely eliminate a previously submitted claim for a specific provider, patient, payer, insured, and statement covers period. We will void the claim from our records. When to Use Claim Frequency Codes Do use claim frequency codes as follows: Use for claims that were originally adjudicated (approved or denied). (Do not use these codes for claims that contained errors and were not processed.) Use for PAR, PPO, ITS, FEP, and HealthKeepers claims. Do not use claim frequency codes in the following situations: Do not submit these codes on paper according to the Anthem Provider Billing Guidelines. All paper adjustment requests must be accompanied by a 151 or submitted via Point of Care. Do not submit these codes for any situations other than late charges, to replace a prior claim or to void a prior claim. You (September 2010) Part II: 2-10 Anthem, Virginia

11 must submit a 151 for all other adjustment requests. Do not submit these codes with negative charges. How to Submit Claim Frequency Codes To submit adjustment codes on the 837 Claim (Professional, Facility, or Dental), include the following information: 1. In Loop 2300, Claim Information (CLM), CLM05-3, include the appropriate Claim Frequency Code as shown in the chart below. If the code equals: File the claim as follows: 5 Late Charge(s) File electronically, as usual. Include only the additional late charges that were not included on the original claim. 7 Replacement of Prior Claim 8 Void/Cancel of Prior Claim File electronically, as usual. File the claim in its entirety, including all services for which you are requesting consideration. File electronically, as usual. Include all charges that were on the original claim. If you use any other number in CLM05-3, we will reject the claim and report it on the Level 3 Adjudicated Claims Response. 2. In Loop 2300, Original Reference Number, REF02 must include the original Anthem internal tracking number. This number can be found on the 835 Payment Advice (Loop 2100, CLP07, Payer Claim Control Number) and on either the Anthem Facility Provider Remittance Voucher or the 835 Supplement on Point of Care. Note: If the original Anthem internal tracking number (claim number) is not received or does not match the internal tracking number that was assigned to the original adjudicated claim, the adjustment request cannot be completed and may result in no action taken. Anthem s Response to Claim Frequency Codes When we receive a valid Claim Frequency Code (5, 7, or 8): When a claim adjustment request is accepted, we report the claim on the Level 3 Adjudicated Claim Response with a status of Inquiry and process it as a 151*. Providers receive the 151* indicating the action taken. The 835 Payment Advice or Remittance Voucher will indicate changes in the reimbursement, if applicable. * We send the 151 response to the provider s financial address on file. If no financial address is present, we send the 151 response to the physical address. If the Frequency Code equals: then: 5 Late Charge(s) We will adjust the original claim to include the additional late charges. 7 Replacement of Prior Claim We will consider the original claim null and void and replace it with this new claim. (September 2010) Part II: 2-11 Anthem, Virginia

12 8 Void/Cancel of Prior Claim We will void the original claim from our records based on this request. If we cannot locate the original claim, based on the information provided, the 151 response will indicate the action to take (send copy of original claim, copy of 835 Payment Advice, etc.). If any other number other than 5, 7, or 8 is used in CLM05-3, we will reject the claim and report it on the Adjudicated Claims Response. Contact Information: EDI Specialists Our EDI Specialists are also available to speak with your vendor or clearinghouse from 8 AM to 5 PM Eastern time, Monday through Friday. EDI Specialists: (804) or (800) NPI Data Elements The following data elements are critical to accurate processing with NPI. To avoid processing delays, take care to accurately enter the values in these data elements. Each of these data elements is explained within the charts in Section 2.2 of this Companion Document. Data Elements Critical to NPI Processing Type Loop(s) Data Element Notes NPI Provider 2010AA (Billing Provider Name) When using NPI, NM108 = XX and NM109 = NPI. Tax ID Number 2010AA (Billing Provider Name) If REF01 (Reference Identification Qualifier) = EI, then REF02 (Billing Provider Additional Identifier) = Tax ID Number. Provider Name 2010AA (Billing Provider Name) In NM103 (Billing Provider Last or Organizational Name) enter the provider name noted on the W-9 (Request for Taxpayer Identification Number and Certification). Physical Address 2010AA (Billing Provider Name) Do not enter a post office box address in N301 (Billing Provider Address Line). Enter the physical address of the institution. Bill Type 2300 (Claim Information) For 837 Institutional claims, we use CLM05 (Health Care Service Location Information) to identify the place of service. Service Facility Name Taxonomy Code 2310E (Service Facility Name) 2000A (Billing/Pay-To Provider Hierarchical Level) Complete the NM1 (Service Facility Name) segment if the services were rendered at a different location than entered in 2010AA N301. PRV03 (Provider Taxonomy Code): When using NPI, enter the taxonomy code that applies to the services on the claim you are filing. (Note to Clearinghouses: Do not default.) (September 2010) Part II: 2-12 Anthem, Virginia

13 2.2 Charts The 837 claim is divided as follows: The Header contains transaction control information. The Detail contains the detail information for the transaction s business function and is subdivided into the following levels: Provider, Loop 2000A Subscriber, Loop 2000B Patient, Loop 2000C Claim Information, Loop 2300 Service Line Number, Loop 2400 This section includes charts to explain the 837 data elements that (1) require specific information for Anthem and (2) are beyond the instructions in the ASC X12N 837 Implementation Guide (837 IG) for Institutional Claims. If a data element does not need additional information for Anthem, it is not documented in this Companion Document. Use this document as an addition and companion to the 837 IG. Note: Before the 837 claim goes to processing, it must pass initial compliance and formatting checks. For complete information, see Part I, Chapter 7, Acknowledgments and Reports, and Part II, Chapter 8, Virginia Business Edits Header The first three 837 Institutional Header segments identify the transaction, the start of the transaction, and the business purpose. The Header also identifies the submitter and the receiver. The following chart explains the header segments and data elements that require specific information for Anthem. Header This chart includes only data elements requiring specific information for Anthem processing. Segment Data Element Value Definitions and Notes Specific to Anthem Loop 1000B Receiver Name NM1 NM103 Receiver Name Receiver Name NM Receiver Primary Page 67 Identifier ANTHEM HEALTH PLANS OF VIRGINIA INC CMSCOS This code represents Anthem Health Plans of Virginia, Inc. (DUNS and a suffix) Note: CMSCOS are alpha characters. (September 2010) Part II: 2-13 Anthem, Virginia

14 Provider Level Loop 2000A Loop 2000A Provider Level Loop 2000A and the subloops provide information about the provider. The following chart explains the 837 provider segments and data elements that require specific information for Anthem. This chart includes only data elements requiring specific information for Anthem processing. Segment Data Element Value Definitions and Notes Specific to Anthem Loop 2000A Billing/Pay-To Provider Hierarchical Level PRV Billing/Pay-To Provider Hierarchical Level PRV03 Provider Taxonomy Code Loop 2010AA Billing Provider Name NM1 Billing Provider Name 837 Page 76 NM103 Billing Provider Last or Organizational Name NM108 Identification Code Qualifier When using NPI, enter the taxonomy code that applies to the services on the claim you are filing. (Note to Clearinghouses: Do not default.) Enter the provider name noted on the W-9 (Request for Taxpayer Identification Number and Certification). NPI Compliant: XX National Provider Identifier (NPI) NPI Exempt: Most trading partners enter XX. Examples of NPI exemptions include taxi services, home modifications, vehicle modifications, insect control, and respite services. NM109 Billing Provider Identifier NPI Compliant: (NPI) NPI Exempt: Most trading partners enter their NPI. Examples of NPI exemptions include taxi services, home modifications, vehicle modifications, insect control, and respite services. N3 Billing Provider Address 837 Page 79 N301 Billing Provider Address Line (Billing Provider Street Address) Do not enter a post office box address. Enter the physical address of the institution. REF Billing Provider Secondary Information 837 Page 82 REF01 Reference Identification Qualifier REF02 Billing Provider Additional Identifier NPI Compliant: EI Employer s Identification Number NPI Exempt: 1A Blue Cross Provider Number NPI Compliant: (Employer s Identification Number) NPI Exempt: (6-Digit Anthem Provider Number) Most trading partners enter EI. Examples of NPI exemptions include taxi services, home modifications, vehicle modifications, insect control, and respite services. The Employer s Identification Number is the provider s tax identification number. Most trading partners enter the Employer s Identification Number. Examples of NPI exemptions include taxi services, home modifications, vehicle modifications, insect control, and respite services. (September 2010) Part II: 2-14 Anthem, Virginia

15 Subscriber Level Loop 2000B Loop 2000B and the subloops provide information about the subscriber. The following chart explains the 837 subscriber segments and data elements that require specific information for Anthem. Loop 2000B Subscriber Level This chart includes only data elements requiring specific information for Anthem processing. Segment Data Element Value Definitions and Notes Specific to Anthem Loop 2000B Subscriber Level SBR Subscriber Information 837 Institutional IG Page 101 SBR01 Payer Responsibility Sequence Number Code P S T Loop 2010BA Subscriber Name NM1 NM108 MI Subscriber Name 837 Institutional IG Page 108 Identification Code Qualifier NM109 Subscriber Primary Identifier Loop 2010BC Payer Name NM1 Payer Name 837 Institutional IG Page 126 NM103 Payer Name NM108 Identification Code Qualifier NM109 Payer Identifier Primary Secondary Tertiary Member Identification Number Enter the ID number as it appears on the front of the ID Card. Examples include: XXX######### XXXX######### XXX###X##### R######## ANTHEM HEALTH PLANS OF VIRGINIA INC PI Payer Identification This COB-related data element is necessary for Anthem when we are secondary or tertiary. If the value equals S or T, then either the data elements documented in this chart are required (see Section 2.1.4, Coordination of Benefits), or Loop 2300 (Claim Supplemental Information), PWK01 (Attachment Report Type Code) must equal EB (Explanation of Benefits). Applies to Medicare and Carriers ID number formats will vary. The examples below show some common formats. Enter the ID number as it appears on the front of the ID card. Format XXX######### XXXX######### XXX###X##### Use for All except FEP Explanation Alphanumeric subscriber identification number as it appears on the front of the ID card R######## FEP R, then the 8- position numeric subscriber ID code Examples YTA AWSS YTA123X56789 R CMSCOS This code represents Anthem Health Plans of Virginia, Inc. (DUNS and a suffix) Note: CMSCOS are alpha characters. (September 2010) Part II: 2-15 Anthem, Virginia

16 Patient Level Loop 2000C Loop 2010C Patient Name Loop 2000C and the subloops provide information about the patient. When the patient is the subscriber, this level is not sent. The following chart explains the 837 subscriber segments and data elements that require specific information for Anthem. This chart includes only data elements requiring specific information for Anthem processing. Segment Data Value Definitions and Notes Specific to Anthem Element Loop 2010CA Patient Name NM1 Patient Name NM108 Identification Code Qualifier MI Member Identification Number 837 Institutional IG Page 145 NM109 Patient Primary Identifier Enter the ID number as it appears on the front of the ID Card. Examples include: ID number formats will vary. The examples below show some common formats. Enter the ID number as it appears on the front of the ID card. Format XXX######### XXX######### XXXX######### XXXX######### XXX###X##### XXX###X##### R######## Use for All except FEP Format Alphanumeric subscriber identification number as it appears on the front of the ID card R######## FEP R, then the 8-position numeric subscriber ID code Examples YTA AWSS YTA123X56789 R Loop 2300 and the subloops provide claim information. Claim Information We recommend that you limit the size of the transaction (ST-SE Loop 2300 Envelope) to a maximum of 5000 CLM Segments. The following chart provides information about the claim level segments and data elements that require specific information for Anthem. Loop 2300 Claim Information This chart includes only data elements requiring specific information for Anthem processing. Segment Data Value Definitions and Notes Specific to Anthem Element Loop 2300 Claim Information CLM Claim We recommend that you limit the size of the transaction (ST-SE Envelope) to a maximum of 5000 CLM segments. Information CLM01 Patient Account Number (Patient Account Number) As indicated in the IG, Anthem supports a maximum of 20 characters in this data element. 837 Page 157 CLM02 Total Claim Charge Amount CLM05 Health Care Service Location Information (Type of Bill) CLM05-3 Claim Frequency Code The value equals the sum of the amounts for all occurrences of 2400 (Service Line), SV203 (Line Item Charge Amount). We use CLM05 to identify the place of service. Enter 1 for original claims. To adjust a previous claim, enter 5 Late Charges, 7 Replacement of Prior Claim, or 8 Void/Cancel of Prior Claim. For complete information on filing a claim adjustment, see Section 2.1.9, Filing Electronic Claims with Adjustment Information. (September 2010) Part II: 2-16 Anthem, Virginia

17 (Continued) Loop 2300 Claim Information This chart includes only data elements requiring specific information for Anthem processing. Segment Data Element Value Definitions and Notes Specific to Anthem (Continued) Loop 2300 Claim Information PWK Claim Supplemental Information Page 173 When documentation is necessary to support an 837 Claim, identify the documentation using this PWK segment or the PWK segment at the service line level (Loop 2400). You should mail or fax the actual supporting documentation. To avoid unnecessary paperwork, obtain any required authorizations, referrals or inpatient admissions and enter the authorization number into Loop 2300 (Claim Information), REF02 (Referral Number). Information about contracts and services that require authorizations is available at Once on the site, select "Providers," then "Virginia," then then Specialty Care/Health Services. In lieu of attachments, you may use the Notes (NTE) Segments if and when appropriate to help describe the service. For example, you may be able to use the NTE segments for unlisted procedure codes or to provide accident information. When a claim requiring either notes or attachments is submitted and we have not received the supporting documentation, then we deny the claim and request the documentation. When the attachment arrives, we adjust the claim. PWK01 Attachment Report Type Code Institutional IG Use the values indicated in the IG to identify the type of attachment. PWK02 Attachment Transmission Code Codes used by Anthem include: AA BM FX EL Available on Request at Provider Site By Mail By Fax Electronic for supporting documentation is not available at this time. If you send supporting documentation by mail or facsimile, include the policy number, patient name, date of service, and provider number in the upper right hand corner. Attach the documentation to a 151 Claim Information Adjustment Request Form with all fields completed. ( is not available at this time.) The mailing address is: P. O. Box Richmond, Va The fax number is: (804) Illegible information will delay processing. PWK05 AC Identification code qualifier AC Attachment Control Number PWK06 Identification code (attachment tracking number) If provider is using MEA for claims attachments, please enter MEA and all alpha/numeric characters assigned as your tracking number. (EX: MEA12345B) K3 File Information Page 204 K301 Fixed Format Information Y N W Yes Nol Clinically Undetermined 1 Unreported/Not Used/Exempt X X, Z POA data terminator POA<value/s> Eff. 1/1/08, Acute Care Hospitals must submit a POA indicator for every principal and other diagnosis on inpatient (TOB 11x and 12x) acute care claims. Examples: K3*POAYYYNUZ~, K3*POAU1NX~ (September 2010) Part II: 2-17 Anthem, Virginia

18 (Continued) Loop2300 Claim Information This chart includes only data elements requiring specific information for Anthem processing. Segment Data Element Value Definitions and Notes Specific to Anthem (Continued) Loop 2300 Claim Information NTE Segments: Claim Note and Billing Note 837 Institutional IG Pages 205 and 208 NTE Claim Note 837 Institutional IG Page 205 NTE Billing Note 837 Institutional IG Page 208 HI Value Information 837 Institutional IG Page 280 The Institutional 837 includes two NTE (Notes) segments, both at the claim level (Loop 2300) as follows: NTE Claim Note NTE Billing Note Each NTE segment allows up to 80 bytes. The Claim Note can be repeated up to 10 times (800 total bytes) and the Billing Note allows no repetition (80 bytes). Therefore, the Claim Note plus the Billing Note allow a total of 880 bytes. When appropriate, if supplemental information can be conveyed in 880 bytes or less, use the NTE segments rather than sending attachments. The Claim Note NTE segment is primarily intended for notes pertaining to the entire claim, and the Billing Note NTE segment is primarily used to provide notes about or a description of the particular service rendered. It is preferable to keep Claim Note within the allotted 800 bytes. If a Claim Note requires more than 800 bytes, you may begin the note in either the Billing Note NTE or Claim Note NTE segment as appropriate and continue it into the other NTE. The continuation is called overflow. When notes apply to a specific service rendered, enter the corresponding Service Line Number from Loop 2400, LX01 at the beginning of the text. In NTE segments, include only pertinent information. Information such as Anthem Blue Cross and Blue Shield, the name of the other insurance carrier or the statement, not a duplicate, may delay processing. NTE02 Claim Note Text NTE02 Billing Note Text See the above note for both NTE segments. See the above note for both NTE segments. There are up to 12 occurrences of this segment. The X in the reference designator (HI0X) can represent any of the numerals 1 through 12, depending on the number of occurrences. Blood Deductible Medicare Only HI0X-1 Code List Qualifier Code HI0X-2 Value Code HI0X-5 Value Code Associated Amount Loop 2310E Service Facility Name NM1 NM101 Service Facility Entity Identifier Code Name NM Institutional Entity Type Qualifier IG NM103 Page 349 Lab or Facility Name Enter BE (Value) Enter 06 (Medicare Blood Deductible) Enter the Blood Deductible amount from the Medicare EOMB. For an explanation of how to enter monetary amounts, see Section 2.1.5, R (Decimal) Data Complete this segment if services were rendered at a different location than entered in 2010AA N301. (September 2010) Part II: 2-18 Anthem, Virginia

19 (Continued) Loop 2300 Claim Information This chart includes only data elements requiring specific information for Anthem processing. Segment Data Element Value Definitions and Notes Specific to Anthem Loop 2320 Other Subscriber Information The following COB-related data elements are necessary for Anthem when we are secondary or tertiary. For a complete explanation of the data elements pertinent to coordination of benefits, see Section 2.1.4, Coordination of Benefits. SBR Other Subscriber Information 837 Page 359 Medicare & SBR01 Payer Responsibility Sequence Number Code P S T Primary Secondary Tertiary Enter the appropriate value to identify the other insurance carrier(s) level of responsibility for payment of this claim. CAS Claims Level Adjustments 837 Page 365 As indicated in the chart below, you can report deductible amounts, coinsurance amounts, and noncovered services in the CAS Segment HI Value Information 2320 CAS Claims Level Adjustments Deductible Coinsurance Non-Covered Services 2320 AMT COB Total Non- Covered Amount AMT Payer Prior Payment 837 Page 371 AMT Coordination of Benefits Total Allowed Amount 837 Page 372 AMT Coordination of Benefits Total Submitted Charges 837 Page 373 Medicare & Only CAS01 Claim Adjustment Group Code CAS02 Adjustment Reason Code CAS03 Adjustment Amount AMT01 Amount Qualifier Code AMT02 Other Payer Patient Paid Amount See See Enter the appropriate Adjustment Group Code found on the 835 Payment Advice, or as identified on the EOB, remittance, or EOMB. Enter the appropriate Adjustment Reason Code found on the 835 Payment Advice, or as identified on the EOB, remittance, or EOMB. Enter the Adjustment Amount found on the EOB, 835 Payment Advice, or EOMB when deductible, coinsurance, copayment and/or non-covered services are reported. For an explanation of how to enter monetary Enter C4 (Prior Payment) For an explanation of how to enter monetary You can report non-covered amounts in either this AMT Segment as explained below or in the CAS (Claims Level Adjustment) Segment. Medicare & Medicare Only AMT01 Amount Qualifier Code AMT02 Allowed Amount AMT01 Amount Qualifier Code AMT02 COB Total Submitted Charge Amount Enter B6 (Allowed-Actual) For an explanation of how to enter monetary Enter T3 (Total Submitted Charges) For an explanation of how to enter monetary (September 2010) Part II: 2-19 Anthem, Virginia

20 (Continued) Loop 2300 Claim Information This chart includes only data elements requiring specific information for Anthem processing. Segment Data Element Value Definitions and Notes Specific to Anthem (Continued) Loop 2320 Other Subscriber Information AMT Coordination of Benefits Total Medicare Paid Amount 837 Page 376 AMT Coordination of Benefits Total Non- Covered Amount 837 Page 386 Medicare Only AMT01 Amount Qualifier Code AMT02 Total Medicare Paid Amount Enter N1 (Net Worth) For an explanation of how to enter monetary You can report non-covered amounts in either this AMT Segment or in the CAS (Claims Level Adjustment) Segment. Medicare & AMT01 Amount Qualifier Code AMT02 Non-Covered Charge Amount Enter A8 (Non-Covered Charges-Actual) For an explanation of how to enter monetary Loop 2330A Other Subscriber Name The following COB-related data elements are necessary for Anthem when we are secondary or tertiary. For a complete explanation of the data elements pertinent to coordination of benefits, see Section 2.1.4, Coordination of Benefits. NM1 Other Subscriber Name 837 Page 400 Medicare & NM103 Other Insured Last Name NM104 Other Insured First Name NM109 Other Insured Identifier Loop 2330B Other Payer Name The following COB-related data element is necessary for Anthem when we are secondary or tertiary. For a complete explanation of the data elements pertinent to coordination of benefits, see Section, 2.1.4, Coordination of Benefits. NM1 Other Payer Name 837 Page 410 Medicare & NM103 Other Payer Last or Organization Name (September 2010) Part II: 2-20 Anthem, Virginia

21 Service Line Loop 2400 Loop 2400 and the subloops provide service line information. The following chart provides information about the line level segments and data elements that require specific information for Anthem. Loop 2400 Service Line Number This chart includes only data elements requiring specific information for Anthem processing. Segment Data Element Value Definitions and Notes Specific to Anthem Loop 2400 Service Line SV2 SV201 Institutional Service Line 837 Page 445 Service Line Revenue Code SV202-2 Procedure Code SV203 Line Item Charge Amount SV206 Service Line Rate Entering a revenue code for total charge (001 or 0001) into this data element is not required, but you may enter it at your discretion. If the last occurrence of this segment equals the total charge, then: the revenue code in this data element must equal 0001, and there must be only one occurrence of revenue code If the value for this data element ends in 9, then either Loop 2300 PWK (Line Supplemental Information), or Loop 2400 PWK (Claim Supplemental Information), or Loop 2300 NTE (Claim Note) is required. When it is necessary to bill unlisted HCPCS (HCFA Common Procedures Coding System), either include a literal description of the procedure in Loop 2300, Segment NTE02 (Description), or complete Loop 2300 PWK (Claim Supplemental Information) or 2400 PWK (Line Supplemental Information) and send supporting documentation as explained in this chart on the next page. For OHAS (Outpatient Hospital Allowance Schedule), HCPCS coding is required. The sum of the amounts of all occurrences this data element is the value entered into 2300 (Claim Information), CLM02 (Total Claim Charge Amount). For an explanation of how to enter monetary amounts, see Section 2.1.5, R (Decimal) Data For an explanation of how to enter monetary amounts, see Section 2.1.5, R (Decimal) Data (September 2010) Part II: 2-21 Anthem, Virginia